A 10-month-old infant has been confirmed with HIV. The nurse knows that:
The infant should be immediately placed on antiretroviral therapy (ART).
The infant should begin ART after turning 12 months old.
Once the infant has a clinical manifestation of AIDS, then ART should begin.
The mother must be mandatorily tested.
The Correct Answer is A
Choice A reason: This statement is correct, as ART is the standard treatment for HIV infection in infants and children, regardless of their age, clinical status, or CD4 count. ART can suppress the viral load, improve the immune function, prevent opportunistic infections, and prolong the survival and quality of life of the infant.
Choice B reason: This statement is incorrect, as delaying ART until the infant turns 12 months old can increase the risk of disease progression, mortality, and drug resistance. The nurse should explain to the parents that early initiation of ART is recommended for all infants with HIV, as they have a high viral load and a rapid decline of CD4 cells.
Choice C reason: This statement is incorrect, as waiting for the infant to have a clinical manifestation of AIDS before starting ART can be too late and ineffective. The nurse should inform the parents that AIDS is the most advanced stage of HIV infection, characterized by severe immunosuppression and life-threatening opportunistic infections. The nurse should emphasize the importance of early diagnosis and treatment of HIV to prevent the development of AIDS.
Choice D reason: This statement is incorrect, as the mother's HIV status is not mandatory to be tested, but voluntary and confidential. The nurse should respect the mother's right to privacy and autonomy, and offer her counseling and testing services if she agrees. The nurse should also educate the mother about the modes of transmission, prevention, and treatment of HIV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because the symptoms described by the mother are not typical of a formula allergy. A formula allergy would cause symptoms such as rash, hives, wheezing, or vomiting within minutes or hours of feeding. Switching to a soy based formula is not recommended without consulting a doctor, as some infants may also be allergic to soy.
Choice B reason: This is incorrect because feeding the infant after vomiting and diarrhea may worsen the condition and cause more dehydration. The infant should be given small amounts of oral rehydration solution (ORS) or breastmilk to prevent fluid loss. If the infant cannot tolerate oral fluids or shows signs of severe dehydration, such as sunken eyes, dry mouth, or lethargy, they should be taken to the emergency department for intravenous rehydration.
Choice C reason: This is incorrect because blood and mucous in the stool are not normal findings in infants and should be investigated promptly. They may indicate a serious condition such as intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. The stool may look like currant jelly due to the presence of blood and mucous. Intussusception is a medical emergency that requires immediate treatment.
Choice D reason: This is correct because the infant's symptoms may indicate a serious condition such as intussusception, which can be life-threatening if left untreated. The infant should be taken to the emergency room for further evaluation and management. The nurse should also advise the mother to monitor the infant's vital signs, hydration status, and urine output until they reach the hospital.
Correct Answer is C
Explanation
Choice A reason: Increased stroke volume is not a correct answer as it means that the heart pumps more blood with each contraction. This would result in increased blood pressure and perfusion, not cool extremities, weak pulses, and low urine output.
Choice B reason: Cardiac arrhythmia is not a correct answer as it means that the heart beats irregularly or abnormally. This can cause palpitations, chest pain, or fainting, but not necessarily cool extremities, weak pulses, and low urine output.
Choice C reason: Decreased cardiac output is a correct answer as it means that the heart pumps less blood than the body needs. This can result from a ventricular septal defect, which causes blood to shunt from the left ventricle to the right ventricle, reducing the amount of oxygenated blood that reaches the tissues. This can cause cool extremities, weak pulses, and low urine output, as well as fatigue, poor growth, and shortness of breath.
Choice D reason: Cyanosis is not a correct answer as it means that the skin, lips, or nails turn blue due to low oxygen levels in the blood. This can occur in some cases of ventricular septal defect, especially if there is pulmonary hypertension or a reversal of the shunt. However, cyanosis is not a direct cause of cool extremities, weak pulses, and low urine output.
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